Barriers to Incident Reporting Among Registered Nurses: A Qualitative Study

Introduction

Incident reporting systems, which allow frontline clinical staff to voluntarily document errors, near-misses, and unsafe conditions, are widely regarded as a foundational component of hospital patient safety infrastructure, providing organizations with a mechanism for identifying systemic vulnerabilities before they result in serious patient harm (Barach & Small, 2000). Because registered nurses spend more direct time at the bedside than any other member of the clinical care team, nursing staff are uniquely positioned to observe and report the conditions, near-misses, and adverse events that inform organizational learning. However, a substantial body of evidence indicates that incident reporting systems consistently capture only a fraction of the errors and near-misses that actually occur in clinical practice, with underreporting estimated to affect anywhere from 50% to over 90% of eligible events depending on event severity and clinical setting (Vincent, Stanhope, & Crowley-Murphy, 1999).

This persistent gap between the true incidence of clinical error and the volume of formally reported events has prompted sustained investigation into the specific barriers that discourage nurses from reporting. Early survey-based research identified fear of disciplinary action, concern about damage to professional reputation, and a belief that reporting would not lead to meaningful change as recurrent themes across multiple hospital settings (Evans et al., 2006). Subsequent qualitative work has extended these findings by illustrating how such barriers are experienced and negotiated by nurses in the course of everyday clinical practice, suggesting that underreporting is shaped not merely by isolated attitudes but by the broader interpersonal and organizational culture surrounding error disclosure (Kingston et al., 2004; Waring, 2005).

Despite this accumulating evidence, much of the existing literature on incident reporting barriers has relied on quantitative survey instruments that, while useful for establishing the prevalence of commonly cited barriers, offer limited insight into how nurses actually experience and reason through the decision to report or withhold a given incident in real time. Qualitative approaches, by contrast, allow for a more nuanced understanding of the relational, emotional, and situational context surrounding reporting decisions, including how prior experiences with reporting, whether personal or observed among colleagues, shape subsequent willingness to disclose (Jeffs et al., 2012). Given that many hospitals continue to invest substantial resources in incident reporting infrastructure without a corresponding increase in reporting volume, a more granular, experience-based understanding of the barriers nurses actually encounter is necessary to inform interventions capable of meaningfully improving reporting culture rather than simply modifying the reporting system’s technical interface.

The purpose of this qualitative study was to explore registered nurses’ perceptions of and experiences with incident reporting in acute hospital settings, with the goal of identifying, in nurses’ own words, the barriers that most strongly discourage the reporting of errors and near-misses, and characterizing how these barriers interact with one another in shaping nurses’ day-to-day reporting decisions.

Methods

This study employed a qualitative descriptive design using semi-structured, individual interviews, an approach well suited to capturing the perspectives and lived experiences of clinical staff regarding a sensitive, potentially stigmatized topic such as error disclosure. Purposive sampling was used to recruit registered nurses from medical-surgical, intensive care, and emergency department units across three acute care hospitals within a single health system, with the goal of capturing variation in unit acuity, reporting volume, and prior individual experience with the formal incident reporting system. Eligible participants held current registered nurse licensure, had at least one year of experience in their current clinical unit, and had direct, hands-on patient care responsibilities. Recruitment continued until thematic saturation was judged to have been reached, defined as the point at which successive interviews no longer yielded substantively new themes or subthemes.

A total of 22 registered nurses participated in the study, including nine from medical-surgical units, seven from intensive care units, and six from emergency department settings, with a mean of 8.4 years of clinical experience. Interviews were conducted individually in a private location away from the clinical unit, lasted between 35 and 62 minutes, and were guided by a semi-structured interview protocol covering participants’ general understanding of the incident reporting process, personal experiences submitting or deciding not to submit a report, perceived organizational response to previously submitted reports, and suggestions for improving the reporting process. All interviews were audio-recorded with participant consent and transcribed verbatim for analysis.

Data were analyzed using reflexive thematic analysis, following the six-phase approach described by Braun and Clarke (2006), including familiarization with the data, generation of initial codes, searching for candidate themes, reviewing and refining themes against the coded data, defining and naming final themes, and producing the final narrative synthesis. Two members of the research team independently coded a subset of transcripts to support analytic rigor, with coding discrepancies resolved through discussion and iterative refinement of the coding framework. Consistent with a qualitative descriptive approach, analysis remained closely grounded in participants’ own language and reported experience rather than applying a predetermined theoretical framework, and illustrative participant quotations are presented using de-identified role and unit descriptors rather than any identifying detail.

Findings

Five interrelated themes were identified from the interview data: fear of blame and disciplinary consequence, perceived futility of reporting in the absence of visible follow-up, ambiguity regarding what constitutes a reportable event, workload and time pressure competing with reporting effort, and a cumbersome, poorly designed reporting system. While each theme is described separately below, participants frequently described these barriers as compounding one another, such that no single factor operated in isolation from the others in shaping an individual reporting decision.

Fear of blame and disciplinary consequence

Fear of individual blame emerged as the most frequently and forcefully described barrier across participants, consistent with prior survey-based findings identifying fear of disciplinary action as a leading deterrent to reporting (Evans et al., 2006). Participants described concern that submitting a report, even one framed around a systemic condition rather than individual performance, would be interpreted by unit leadership as an admission of personal fault with consequences for performance evaluation, assignment, or standing among colleagues. Several participants described having personally witnessed a colleague face visible disciplinary consequence following a submitted report, an experience that appeared to exert an outsized influence on their own subsequent reporting behavior, a pattern consistent with prior findings that observed punitive response, not merely personally experienced punitive response, can suppress reporting behavior across an entire unit (Kingston et al., 2004).

“After what happened to a nurse on our unit, everyone kind of quietly agreed that unless something is really serious, you just handle it yourself and move on. Nobody wants to be the next example.”— Participant 11, Medical-Surgical Nurse

Notably, several participants distinguished between reporting near-misses, events that did not reach the patient or cause harm, and reporting events that resulted in actual patient harm, describing greater willingness to report the latter given the perceived unavoidability of disclosure once harm occurred, but describing near-misses as far more discretionary and therefore far more likely to go unreported, a distinction consistent with prior evidence that near-miss events are disproportionately underreported relative to harm events despite arguably offering greater organizational learning value (Jeffs et al., 2012).

Perceived futility of reporting

A second dominant theme concerned participants’ perception that submitting a report was unlikely to produce any visible organizational response or systemic change, a perception that appeared closely intertwined with, and mutually reinforcing of, fear of blame. Many participants described having submitted reports in the past without ever receiving acknowledgment, feedback, or evidence that the underlying issue had been addressed, an experience that led directly to reduced motivation to report subsequent, similar events. This finding is consistent with prior research identifying absence of feedback following a submitted report as one of the most consistently cited reasons for subsequent reporting reluctance across multiple hospital settings (Vincent, 2004; Hartnell et al., 2012).

“I’ve filled out the same report about the same broken equipment three times over two years. At some point you just stop, because clearly it goes into a black hole and nothing happens.”— Participant 6, Emergency Department Nurse

Several participants explicitly framed this perceived futility as more discouraging to future reporting than fear of blame alone, suggesting that even nurses who did not personally fear disciplinary consequence would eventually disengage from reporting if their effort appeared to produce no discernible organizational response, a pattern echoing prior findings that closing the feedback loop between reported incidents and visible corrective action is among the strongest predictors of sustained reporting engagement (Hartnell et al., 2012).

Ambiguity regarding reportable events

A third theme concerned genuine uncertainty among participants regarding which events met the threshold for formal reporting, particularly for near-misses and borderline situations that did not clearly meet participants’ mental model of a reportable “error.” Several participants described a lack of clear, consistently applied institutional guidance regarding what should be reported, leading individual nurses to rely on informal, unit-specific norms that varied considerably even within the same hospital system, a pattern consistent with prior findings that inconsistent or unclear reporting criteria contribute independently to underreporting beyond the influence of blame-related concerns alone (Kingston et al., 2004).

“Honestly, half the time I’m not even sure if something counts. Is a delayed medication by twenty minutes something I report, or is that just Tuesday in this unit?”— Participant 17, Intensive Care Nurse

Workload and time pressure

A fourth theme concerned the practical burden that reporting imposed on already time-constrained nursing staff. Participants across all three unit types described the reporting process as time-consuming relative to the perceived benefit, particularly during high-acuity shifts where completing a detailed incident report competed directly with immediate patient care demands. Several participants indicated that they would be substantially more likely to report an event if the process could be completed more quickly or deferred to a later point in the shift without loss of relevant detail, a finding broadly consistent with prior research identifying reporting burden and time cost as a measurable, independent barrier distinct from psychological or cultural concerns (Force et al., 2006).

A cumbersome reporting system

Finally, participants frequently described the technical design of the electronic incident reporting system itself as a barrier, citing an unintuitive interface, excessive required fields, and difficulty locating the reporting tool within the broader electronic health record platform. Several participants contrasted the incident reporting system unfavorably with other digital tools used routinely in clinical practice, suggesting that the comparative difficulty of the reporting interface itself discouraged use independent of any psychological or cultural barrier, a finding consistent with prior evidence that system usability exerts a measurable, independent influence on reporting rates (Force et al., 2006; Hartnell et al., 2012).

Discussion

The findings of this study indicate that underreporting of incidents among registered nurses is not attributable to any single dominant barrier but instead reflects the cumulative and mutually reinforcing interaction of psychological safety concerns, perceived organizational responsiveness, ambiguity regarding reporting criteria, workload pressure, and system usability. The particularly close relationship observed between fear of blame and perceived futility, in which each barrier appeared to compound the discouraging effect of the other, suggests that interventions targeting either factor in isolation are unlikely to substantially improve reporting behavior, a conclusion consistent with prior calls to address reporting culture and reporting infrastructure as an integrated system rather than as separable technical and cultural problems (Waring, 2005).

The prominence of fear of blame identified in this study is consistent with a substantial body of prior literature describing the persistence of a punitive culture surrounding error disclosure in many hospital settings, despite widespread formal organizational commitment to “just culture” or non-punitive reporting principles (Kingston et al., 2004; Waring, 2005). The finding that observed, rather than only personally experienced, punitive consequence appeared sufficient to suppress future reporting across an entire unit suggests that the reputational and cultural consequences of even a single visible disciplinary action following a report may extend far beyond the individual nurse directly involved, underscoring the importance of leadership transparency and consistency in how reported events are handled, and how that handling is subsequently communicated to the broader unit.

The theme of perceived futility offers a particularly actionable insight for hospital leadership, as it suggests that closing the feedback loop between report submission and visible corrective action may represent a comparatively tractable intervention relative to the more deeply embedded challenge of shifting blame-oriented culture. Participants’ descriptions of repeated, unacknowledged reports regarding the same unresolved issue point to a specific, addressable organizational failure distinct from psychological fear of punishment, and prior research similarly suggests that visible, timely feedback following a submitted report is among the strongest predictors of sustained reporting engagement over time (Hartnell et al., 2012; Vincent, 2004).

The theme of ambiguity regarding reportable events suggests a need for clearer, more consistently communicated institutional guidance regarding reporting thresholds, particularly for near-miss events that fall outside nurses’ intuitive conception of a clinical “error.” Given that near-misses are widely regarded as offering substantial organizational learning value precisely because they occur far more frequently than harm events and can be examined without the complicating factor of patient injury, addressing this ambiguity may meaningfully increase the overall volume and diagnostic value of submitted reports (Jeffs et al., 2012; Barach & Small, 2000).

Finally, the workload and system usability themes identified in this study reinforce prior findings that reporting burden operates as a measurable, independent barrier distinct from psychological or cultural concerns, and that technical improvements to reporting system design, including simplified interfaces, reduced required fields, and closer integration with existing clinical documentation workflows, may yield meaningful improvement in reporting rates even absent broader cultural change (Force et al., 2006). However, participants’ accounts in this study suggest that technical and cultural barriers operate in parallel rather than as substitutes for one another, and that addressing system usability alone, without corresponding attention to blame culture and feedback responsiveness, is unlikely to produce durable improvement in reporting behavior.

This study is subject to several limitations. As a qualitative study conducted within a single health system, findings may not fully generalize to hospital settings with different organizational culture, reporting infrastructure, or disciplinary practice. Participants volunteered to discuss a sensitive topic involving personal and observed error, and it is possible that nurses with the most strongly negative reporting experiences were more, or alternatively less, likely to volunteer for participation, introducing potential selection bias in either direction. Additionally, because data collection relied on retrospective self-report of past reporting decisions, participant accounts may be subject to recall bias or reinterpretation in light of subsequent events.

Future research would benefit from longitudinal or mixed-methods designs capable of tracking whether specific interventions targeting the barriers identified here, including structured feedback protocols following report submission, simplified reporting interfaces, and leadership-led non-punitive response to reported events, produce measurable improvement in reporting volume and near-miss capture over time. Comparative qualitative work across health systems with differing reporting cultures and disciplinary practices would further help clarify which of the barriers identified in this study are most amenable to organizational intervention, and future studies might also usefully examine whether newer nurses, still forming their professional norms around disclosure, experience these barriers differently than the more experienced participants who predominated in this sample. Taken together, these findings suggest that meaningful improvement in incident reporting among registered nurses will likely require simultaneous attention to psychological safety, feedback responsiveness, reporting clarity, and system usability, rather than reliance on any single reform in isolation.

References

Barach, P., & Small, S. D. (2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ, 320(7237), 759–763.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.

Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O’Shaughnessy, J., & DeWit, M. (2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality and Safety in Health Care, 15(1), 39–43.

Force, M. V., Deering, L., Hubbe, J., Andersen, M., Hagemann, B., Cooper-Hahn, M., & Peters, W. (2006). Effective strategies to increase reporting of medication errors in hospitals. Journal of Nursing Administration, 36(1), 34–41.

Hartnell, N., MacKinnon, N., Sketris, I., & Fleming, M. (2012). Identifying, understanding and overcoming barriers to medication error reporting in hospitals. BMJ Quality & Safety, 21(5), 361–368.

Jeffs, L., Berta, W., Lingard, L., & Baker, G. R. (2012). Learning from near misses: From quick fixes to closing off the Swiss-cheese holes. BMJ Quality & Safety, 21(4), 287–294.

Kingston, M. J., Evans, S. M., Smith, B. J., & Berry, J. G. (2004). Attitudes of doctors and nurses towards incident reporting: A qualitative analysis. Medical Journal of Australia, 181(1), 36–39.

Vincent, C. (2004). Analysis of clinical incidents: A window on the system not a search for root causes. Quality and Safety in Health Care, 13(4), 242–243.

Vincent, C., Stanhope, N., & Crowley-Murphy, M. (1999). Reasons for not reporting adverse incidents: An empirical study. Journal of Evaluation in Clinical Practice, 5(1), 13–21.

Waring, J. J. (2005). Beyond blame: Cultural barriers to medical incident reporting. Social Science & Medicine, 60(9), 1927–1935.

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